CHAPTER 24
MEDICATION ADMINISTRATION
(CHARTING, DOCUMENTATION AND THE MED PASS )
NURSING HOME
Medication Administration and Charting in the Nursing Home
(UNDER QUALITY OF CARE REQUIREMENTS)
I.Facility is responsible for administering drugs, timely, as ordered
1.Charting
2.Pharmacy stopping meds - re: no pay
3.Pharmacy not supplying in a timely way
4.Automatic stop order responsibility
II.Drugs given as ordered and checked against the orders
1.Use of MAR
2.Patient identification
3.Dose recorded by nurse administering
4.Nurse identifies initials
5.Doses given by nurse preparing as soon as possible after preparing
III.If orders not given as ordered:
1.Is there an explanation?
2.Is there an incident report?
IV.PRN medications
1.Documentation - why given and results
2.Use of PRNs
3.How to reduce numbers of PRNs
V.Crushing medications
1. There must be an order
2. The facility should NOT use ancillary orders allowing crushing of medication
NURSING HOME
Federal Survey Manual
483.60 Pharmacy Services.
F366The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.75 (j) of this part.
Interpretive Guidelines: 483.60.The facility is responsible under 483.75 (j) for the timeliness of the services.
Survey Procedures and Probes: 483.60.During your observation of the drug pass are all needed medications available? If one drug is not available for the resident at its scheduled time of administration AND the omission of that drug can cause the resident discomfort or endanger his or her health and safety, a negative finding should be recorded.
465(1)Administration means the obtaining and giving of a single dose of medicinal drugs by a legally authorized person to a patient for his consumption.
NURSING HOME
SAMPLE POLICY & METHODS
Drug Administration
POLICY:
All medications are to be administered only as prescribed and only by licensed medical or nursing personnel.
METHODS:
1.Drug administration is the act in which a single dose of an identified drug is given to a patient.
2.Drugs shall be administered in compliance with all local, state and federal laws.
3.The nursing director is responsible for the accurate handling and precise administration of drugs to the patient.
4.The physician orders should be checked before administering medications.
5.Drugs are to be administered as soon as possible after being prepared by the person preparing them.
6.The administration of medications will be done by a nurse, LPN or RN, who holds a current valid Florida license, or a graduate nurse under the direct supervision of an RN.
7.All nursing personnel assigned to administering medications shall identify their initials by signing their full signature once each month on the medication administration record.
NURSING HOME
PRN Orders in the Nursing Home
1.Receipt of orders by nurse
a.conditions for which given
b.How long given? How frequently given?
2.Vendor pharmacists to be informed
a.How long will the medication be given?
b.How frequently will it be used?
3.The physician should be informed if resident is getting the PRN on a regularly scheduled so the order can be changed.
4.Procedures to DC if not used in 60 days? 90 days?
5.When administered:
a.Document that a PRN has been given
(1)on the MAR
(2)on the back of the MAR
(3)nursing notes
(4)elsewhere
b.Document what was the complaint
c.Document the time given, the dose, the route of administration, and if
appropriate the injection site
d.Results achieved, no results achieved
e.The nurse’s signature
6.Review by the pharmacist
NURSING HOME
SAMPLE POLICY & METHODS
PRN Medications
POLICY:
PRN medications shall be provided to the residents as ordered by the physician and proper documentation of their usage shall be maintained.
METHODS:
1.The nurse receiving the order for a PRN medication should obtain from the physician the condition or conditions for which the medication should be given.
2.The pharmacist should be informed whether the medication is expected to be used for a short or long period of time when ordering the medication to reduce the amount of medication that could be wasted.
3.When a PRN medication is administered, the nurse should properly document in the chart the following:
a.The complaint or the symptom for which the drug was given.
b.The dose, time, route of administration, and if appropriate the site of the injection.
c.The results achieved or the statement no results achieved.
d.The nurse’s signature.
NURSING HOME
SAMPLE POLICY & METHODS
Refused Medications
POLICY:
It is the policy of this facility to encourage all residents to take medications as ordered by their physician.
METHODS:
1.It is the right of each resident to refuse or accept medications ordered by their physician.
2.It is the responsibility of the facility and the staff and in the best interests of the resident to encourage those residents who refuse medications to accept them.
3.All medications refused by a resident shall be identified in the chart as having been refused with an explanation in writing on the back of the medication administration form, if known, as to why the medications were refused.
4.If medications are refused routinely or in the judgment of the nurse, a significant number of times the unit manager shall be notified. The unit manager shall request the assistance of the family, the social services worker, etc. in getting the resident to accept the medication.
5.If the unit manager is unsuccessful in getting the resident to accept the medication, the physician shall be contacted and asked to discontinue the orders. If the physician refuses to change the orders, it shall be documented in the chart. Each month thereafter the chart should reflect that the physician is aware of the refusal and the staff regularly encourages the resident to accept the medication.
*Note: the unit manager may designate follow-through to the charge nurse.
THE CONSULTANT PHARMACIST’S
REVIEW OF CHARTING DOCUMENTATION
- Regulation requires every 30 days. Part of Unit Dose System. Must be attached or kept on/in the Unit Dose System when administering medications to patients.
- Hospital - Should normally occur at time of order entry.
Nursing home – Review by Consultant Pharmacist.
- Two basic types
a. Manual
1. Pharmacy Profile and Nursing MAR
2. Pharmacy and nursing use same profile or MAR
b. Automated
Ideal – if pharmacy and nursing system is same
- Efficient
- Reduces opportunity for error
- Uses same terminology and drug descriptions
- Charting on MAR
Initial in time box when medication administered.
Scheduled doses NOT given - circle time box and indicate on back page reason why not given.
- Verification process - IMPORTANT check and balance.
Questions and Answers About the Medication Error Detection Methodology
1.Q:What improvement over the old survey method does the observational
method offer?
A:The observational method relies on the surveyor actually seeing or not seeing the drugs being administered and comparing that observation to the Physician’s order. This provides direct evidence as to whether the drugs were administered in accordance with physician’s orders. The technique does not rely on paper review which only provides indirect evidence that a medication error has occurred. The paper review techniques has in fact resulted in facility personnel correcting the paper while actual errors continue to occur.
2.Q:Won’t observation of the administration of medications distract the nursing staff?
A:Yes initially, but the observer is trained to put the individual administering medications at ease. When put at ease, this individual will resort to their usual habit patterns. If those habit patterns are error producing, the Observer will see them.
3.Q:Why does the surveyor have to identify in a positive way each drug during the pour?
A:Positive identification of the drug is the most critical aspect of the observation technique. Positive identification of the drug is imperative in order to make a valid comparison between what was actually administered and what the physician ordered.
4.Q:How does this problem of identifying each drug apply to the unit dose ystem?
A:Identification of the drug is crucial regardless of the distribution system used. Most surveyors find it easier to identify a drug under the unit dose system however.
5.Q:Will the nursing staff become more aware of medication errors as a result of the observational method?
A:Yes, most individuals administering medications are not aware that they are making errors. The observation technique will identify these previously undetected errors.
6.Q:Won’t this method take more surveyor time?
A:Yes, the net time is between 30 to 60 minutes longer depending on the drug distribution system used and the speed of the surveyor.
7.Q:Will the medication error detection methodology change the drug regimen review recommendation of consultant pharmacists?
A:Perhaps. If the surveyor identifies an appreciable number of medication errors. The consultant pharmacist may no longer be willing to assume correct administration of the drug in making recommendations to physicians.
8.Q:Would it be useful for LTCF consultant pharmacists to observe medication administration in the manner of surveyors? Wouldn’t this make nursing staffs more familiar with the observational method and less distracted by it?
A:If any member of the facility staff including the consultant pharmacist wished to conduct medication error studies using the observation technique it would be useful to the facility and especially to its patients.
9.Q:If the surveyors observe and record medication administration of 20 patients who are selected by them, will the record of other patients not be reviewed?
A:If a surveyor did not feel that the records examined as part of the medication error detection methodology were representative of the facility for other survey purposes (e.g. nursing), then he or she would be obliged to examine other than these 20 records until a representative sample was reviewed.
10.Q:How will nursing staffs learn what are “significant” and non-significant” errors?
A:Implicit in your question is the idea that one needs to differentiate between the two so that significant errors can be more vigorously avoided. That is not what we want to happen. One must remember that if “non-significant” errors exceed 5 percent, the facility will be cited on the theory that errors of this magnitude indicate that the drug distribution system is flawed and sooner or later will cause significant errors.
11.Q:Is the medication error detection methodology a regulation?
A:No! It is a surveyor procedure that must be used to determine compliance with Medicare and Medicaid regulations.
12.Q:Will improper drug administration procedures such as failure to measure a liquid at eye level result in a medication error?
A:Not necessarily. If measuring the liquid this way resulted in the wrong dose being administered, then it would be called an error.
13.Q:Why will the observation technique as opposed to the paper review technique be more likely to change the behavior of facility staff?
A:The identification of paper errors does not hold as much significance as the identification of actual errors. Consequently it is expected that facility staff will genuinely endeavor to find the cause of actual errors.
FQA-733:Skidder:lm:3/16/84
1859A:Uncontrolled
483.25 (m)Level B requirement: Medication errors
The facility must ensure that ...
F310(1)It is free of significant medication error rates; and
F311(2)Residents are free of any significant medication errors.
Interpretive Guideline: 483.25(m).
A.Dose Reconciliation Technique: Observation Technique
I.Medication error means a discrepancy between what the physician ordered and What the surveyor observes during an observation of several different individuals administering drugs to residents in the facility.
II.Significant medication error means one which causes the resident discomfort or jeopardizes his or her health and safety. Criteria for judging significant medication errors as well as examples are provided under V.
- Medication error rate is determined by calculating the percentage of errors. The numerator in the ratio is the total number of errors that you observe, both significant and insignificant. The denominator is all the doses you observed being administered plus the doses ordered but not administered. The equation for calculating a medication error rate is as follows:
Medication Error Rate = Number of Errors Observed divided by The Opportunities for Errors x 100.
IVSignificant medication error rate means that in a sample of residents chosen for observation of medication administration, a number of errors in medication administration have occurred. The determination of whether a significant medication error rate occurs is a matter of surveyor judgment. A 5% threshold may indicate a significant medication error rate exists, particularly when the individual medication errors are significant. The facility must remain free of significant medication errors rates.
V.Significant and non-significant medication errors
A.General Rules for Determining Significance - The relative significance of medication errors is a matter of professional judgment. Surveyors who are responsible for assessing these requirements must be qualified to exercise such judgment (e.g., pharmacists, nurses). Follow three general rules in determining whether a medication error is significant or not:
1.Resident Condition - The resident's condition is an important factor to take into consideration. For example, a potent diuretic erroneously administered to a dehydrated resident may have serious consequences, but if administered to a resident with a normal fluid balance may not. If the resident's condition requires rigid control, a single missed or wrong dose can be highly significant.
2.Drug Category - If the drug is from a category that usually requires the resident to be titrated to a specific blood level, a single medication error could alter that level and precipitate a reoccurrence of symptoms or toxicity. This is especially true if the half life of the drug is short. Examples of drug categories which require titration of resident blood levels include anticonvulsants, anticoagulants, and antiarrhythmic, anti-anginal and antiglaucoma agents.
3.Frequency of Error - If an error is occurring with any frequency, there is more reason to classify the error as significant. For example, if a resident's drug was omitted several times, as verified by reconciling the number of tablets delivered with the number administered, classifying that error as significant would be more in order. This conclusion may be especially valid when taken in concert with the resident's condition and the drug category.
B.Examples of Significant and Non-Significant Medication Errors - Examples of medication errors that have actually occurred in long-term care facilities are presented below. Some of these errors are identified as significant. This designation is based on expert opinion without regard to the status of the resident. Most experts concluded that the significance of these errors, in and of themselves, have a high potential for creating problems for the typical long-term care facility resident. Those errors identified as non- Resident status and frequency of error could classify these errors as significant.
1.Omissions (drug ordered but not administered at least once)
Haldol 1 mg BIDNS
Motrin 400 mg TIDNS
Quinidine 200 mg TIDS
Tearisol Drops 2 both eyes TIDNS
Indocin 25 mg TID pcNS
Lioresal 10 mg TIDNS
Thorazine 25 mg BIDNS
Ampicillin 500 mg TIDNS
Metamucil one packet BIDNS
Inderal 20 mg one very 6 hrs.S
Multivitamin one dailyNS
Mylanta Susp. One oz., TID ACNS
Nitrol Oint. One inchS
Librium 10 mg one TIDNS
Cortisporin Otic drop 4 to 5
Left ear QIDNS
Aldactone 25 mg QIDNS
2.Unauthorized Drug (drugs administered without a physician's order)
FeosolNS
Coumadin 4 mgS
Lasix 40 mgS
Zyloprim 10 mgNS
Tylenol 5 grNS
Triavil 4-25NS
MultivitaminsNS
Motrin 400 mgNS
3.Wrong dose
OrderedAdministered
Isoptocarpine 1%three drops in
one drop in theEach eyeNS
left eye TID
Epinal 1% one dropthree drops inNS
in eyes BIDEach eye
Digoxin 0.125 mg0.25 mgS
everyday
Lasix 20 mg one daily40 mgNS
Amphojet 30cc QID15 ccNS
Slow K two TIDOneNS
Dilantin 125 susp 12 cc2 ccS
Lasix 40 mg daily20 mgNS
4.Wrong route of administration
Ordered Administered
Hydergine 0.5 mgresidentNS
SL.L. BidSwallowed
Cortisporin OticLeft eyeS
drops 4-5 left ear QID
5.Wrong dosage form
Ordered Administered
Colace LiquidCapsuleNS
100 mg BID
Mellaril 10 mg ConcentrateNS*
(*if correct dose was given)
Dilantin KapsealsPrompt PhenytoinS**
100 mg three kapseals100 mg three
p.o. HSCapsules p.o. HS
(**Park Davis Kapseals have an extended rate of absorption. Prompt phenytoin capsules do not.)
6. Wrong dose
OrderedAdministered
Tylenol 325 mgAscriptinS
(Routinely)
7.Wrong time
OrderedAdministered
Indocin 25 mg PCACNS
Perlactin 4 mg PCACNS
Digoxin 0.25 mgAt 9:15 amNS
daily at 8AM
Tetracycline 250 mgPCS
QID AC and HS
S = Significant NS = Not significant
VI.Rules for Determining Medication Errors
A.Timing Errors
If a drug is ordered before meals (AC) and administered after meals (PC) always count this as a medication error. Likewise if a drug is ordered PC and is given AC. Count a wrong time error if the drug is administered 60 minutes earlier or later than it scheduled time of administration, BUT ONLY IF THAT WRONG TIME ERROR CAN CAUSE THE RESIDENT DISCOMFORT OR JEOPARDIZE THE RESIDENT'S HEALTH AND SAFETY. Counting a drug with a long half-life (e.g., digoxin) as a wrong time error when it is 15 minutes late is improper because this drug has a long half-life (beyond 24 hours) and 15 minutes has no significant impact on the resident. The same is true for many other wrong time error (except AC and PC errors) in long-term care facilities.
To determine the scheduled time, examine the facility’s policy relative to dosing schedule. The facility’s policy should dictate when it administers AM doses, or when it administered the first dose in a 4 times a day dosing schedule.
B.Physician’s Orders
The latest recapitulation of the drug orders (monthly "recap") is sufficient for determining whether a valid order exists provided the physician has signed the "Recap" This signed "recap" and subsequent orders constitute a legal authorization to administer the drug. Attempts to find original orders in the physician’s handwriting are usually too time consuming.
Survey Procedures and Probes: 483.25(m)
I.Medication Error Detection Methodology Use an observation technique to determine medication errors. This means that you must observe the administration of drugs (on several different drug passes); record what is observed; and reconcile the record of observation with the physician’s drug orders to determine whether or not medication errors have occurred.